Impact of Racist Microaggressions and LGBTQ-Related Minority Stressors: Effects on Psychological Distress Among LGBTQ+ Young People of Color

Background College students situated at the nexus of racial and sexual and gender minority (SGM) identities may experience multiple identity-related oppressions. We assessed whether racist microaggressions and lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ)–related minority stressors (ie, family rejection, identity concealment, racialized heterosexism and/or cisgenderism, internalized LGBTQ-phobia, and victimization) are associated with greater psychological distress among SGM college students of color (SOC) (students who identified as Hispanic/Latinx and/or any nonwhite race). Methods Participants were a subset of SOC (n = 200) from a larger nonprobability cross-sectional study of SGM college students. Participants were recruited by using online social media platforms and university email listserves from May through August 2020. Participants completed an online Qualtrics survey using previously validated measures of minority stress, racist microaggressions, and psychological distress. Simple and covariate-adjusted multiple linear regression models were used to examine the associations between racist microaggressions and LGBTQ-related minority stressors with psychological distress. Results In simple linear regression models, racist microaggressions and all LGBTQ-related stressors (ie, family rejection, identity concealment, racialized heterosexism and/or cisgenderism, internalized LGBTQ-phobia, and victimization) were significantly and positively associated with greater psychological distress. In covariate-adjusted multiple linear regression, racist microaggressions, internalized LGBTQ-phobia, and LGBTQ-related family rejection (but not identity concealment, racialized heterosexism and/or cisgenderism, and victimization) were independently and significantly associated with greater psychological distress. Conclusion Study findings reveal that racist microaggressions, along with LGBTQ-related family rejection and internalized LGBTQ-phobia, have a significant impact on psychological distress among SGM SOC. Public health leaders have an important opportunity for policy and program development and reform to address the identity-related mental health needs of SGM SOC.


Introduction
The negative mental health impacts of interpersonal racism have been established (eg, racist discrimination, racist microaggressions) (1,2) and lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ)-related identity concealment (3), victimization (4), internalized homophobia (5), and family rejection (6) among sexual and gender minority (SGM) people and people of color (POC, anyone who identifies as Hispanic/Latinx and/or a nonwhite race). Further, existing research indicates that dual experiences of interpersonal racism and LGBTQ-related stressors (ie, gay rejection sensitivity, homonegativism, and heterosexism) have strong negative effects on the psychological health of SGM POC, including declines in mental well-being and increases in psychological distress, depression, and anxiety (1,7,8). However, few studies have examined the effects of interpersonal racism (ie, racist microaggressions) along with multiple forms of LGBTQ-related stress (ie, identity concealment, family rejection, internalized homophobia, victimization). Given existing literature linking more singular forms of LGBTQ-related stress and interpersonal racism with their negative effects on mental health, this is a substantial gap in the scientific literature. Unfortunately, the experience of LGBTQ-related stressors may be complicated when considering interpersonal racism (stressors that are unique to POC), including anti-Black (9) and anti-Asian (10) racism or racism-related stressors, as well as anti-immigrant and anti-Latinx discrimination and xenophobia (11). Additionally, interpersonal racism against SGM POC can often manifest as an intracommunity form of discrimination, in which SGM POC are racially discriminated against by (often white) SGM people (12,13). Given that 41% of all young persons in the US are currently enrolled in college, nearly half (45%) of which are POC (14), and the identity-related vulnerabilities faced by SGM POC, it is highly important to investigate the unique effects of multiple identity-related stressors that are likely affecting the mental health of SGM students of color (SOC, any college student who identifies as Hispanic/Latinx and/or a nonwhite race), such as interpersonal racism and LGBTQ-related minority stressors. The risk for the multiple experience of LGBTQ-related minority stressors and interpersonal racism may place the mental well-being of SGM SOC in a hypervulnerable position.
Our study used the minority stress theory (15,16), which emphasizes the role of externalized (eg, discriminatory events perpetrated against SGM persons) and internalized (eg, homophobic feelings related to SGM identities) minority stressors and their effects on mental health among SGM persons. Our study implemented minority stress theory by including measures of LGBTQ-related identity concealment, family rejection, victimization, internalized LGBTQ-phobia, and racialized heterosexism and/or cisgenderism.
This study also used Critical Race Theory (CRT) (17,18), a methodologic framework focused on countering racist systems of oppression that lead to health inequities that negatively affect POC. Specifically, our study employs CRT by 1) acknowledging that racism is a central social determinant of health inequities among POC, 2) focusing on groups of people who are disadvantaged and marginalized by their social positionalities and aiming to amplify their experiences and needs (ie, SGM SOC), 3) highlighting racism as a substantial and relevant contributor to the mental health outcome of interest (ie, racist microaggressions and LGBTQrelated stressors affect psychological distress), and 4) acknowledging that racism is a structural issue that manifests interpersonally through common, every day, and frequent occurrences, such as racist microaggressions, which are substantial and impactful forms of racism. Our study was further guided by the intersectionality principle of CRT, which emphasizes that the amalgamation of vulnerable social positionalities and multiple forms of oppression likely produce mental health-related inequities (17,18); in our study, we used intersectionality to understand multiple forms of oppression (ie, LGBTQ-related minority stressors and racist microaggressions) among SGM SOC and how they relate to psychological distress.
We examined whether racist microaggressions, along with multiple LGBTQ-related minority stressors (ie, identity concealment, family rejection, victimization, internalized LGBTQ-phobia, and racialized heterosexism and/or cisgenderism), are associated with greater psychological distress. We hypothesized that racist microaggressions and all LGBTQ-related minority stressors would significantly and positively associate with greater psychological distress. The results of this study may provide useful information relevant for developing, reforming, and changing policies, practices, and programs to address racial, sexual, and gender minority identity-related oppression and mental health needs among SGM SOC.

Study design and sample
The data analyzed in this study were derived from nonprobability cross-sectional data collected from a sample of SGM students (N = 565) to explore minority stress and mental health among SGM college students. A subset of racial and ethnic minority students (n = 200) was used for this analysis (identified as Hispanic/Latinx or a nonwhite race or both). Eligibility criteria for the parent study included being at least 18 years of age, identifying as a sexual or gender minority person, and being a full-time, currently enrolled college student. Data were collected from May 27 through August 14, 2020, via online survey. Participants were incentivized with a PREVENTING CHRONIC DISEASE VOLUME 20, E63 PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY JULY 2023 The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, raffle for a $50 Amazon gift card. Participants were recruited by using an electronic recruitment flyer distributed via multiple social media platforms that included a link to an online Qualtrics survey. Additionally, recruitment occurred through email campaigns within the study implementation team's internal and external professional networks, and at historically Black colleges and universities (HBCUs), Hispanic-serving institutions, and LGBTQ+ student centers across the US. University of Maryland institutional review board approval and participant informed consent were obtained before commencing data collection. Survey duration was approximately 20 to 25 minutes. On completion of the survey, participants were provided a list of mental health and crisis management resources and contact information for the study principal investigator.

Racist microaggressions (perpetrated by white LGBTQ people)
Racist microaggressions were measured by using an adapted version of 5 items from the LGBT People of Color Microaggressions Scale (19). To capture past year racist microaggressions, students were asked to indicate whether they experienced each item in the past year (yes/no). The scale demonstrated strong internal consistency in the current sample (α = .85). A composite score was calculated by summing responses across the 5 items (range, 0-5; mean [SD], 1.90 [2.01]).

LGBTQ-related identity concealment
LGBTQ-related identity concealment was measured by using an adapted version of 3 items from the LGBT Minority Stress Measure (LMSM) (20) and 4 items from the Daily Heterosexist Experiences Questionnaire (DHEQ) (21). To capture past year identity concealment, students were asked to indicate whether they experienced each item in the past year (yes/no). A composite score was calculated for all 7 items (range, 0-7; mean [SD], 3.76 [2.09]). The scale demonstrated strong internal consistency in the current sample (α = .79).

LGBTQ-related victimization
Victimization was measured by using an adapted version of 4 items from the DHEQ (21) and 2 items from the LMSM (20). To capture presence of past year victimization, students were asked to indicate whether they experienced each item in the past year (yes/ no). A composite score was calculated by summing responses across the 6 items (range, 0-6; mean [SD], 0.41 [0.89]; α = .66).

LGBTQ-related family rejection
Family rejection was measured by using an adapted version of 10 items from the Sexual Minority Adolescent Stress Inventory (22) and 7 items from the DHEQ (21). To capture past year family re-jection, students were asked to indicate whether they experienced each item in the past year (yes/no). A composite score was calculated by summing responses across the 17 items (range, 0-17; mean [SD], 5.89 [4.14]). The scale demonstrated strong internal consistency in our sample (α = .86).

Internalized LGBTQ-phobia
Internalized LGBTQ-phobia was measured by using an adapted version of 7 items from the LMSM (20). To capture past year internalized LGBTQ-phobia, students were asked to indicate whether they experienced each item in the past year (yes/no). A composite score was calculated by summing responses across the 7 items (range, 0-7; mean [SD], 1.06 [1.89]). The scale demonstrated strong internal consistency in our sample (α = .83).

Racialized heterosexism and/or cisgenderism
Racialized heterosexism and/or cisgenderism was measured by using an adapted version of 5 items from the LGBT People of Color Microaggressions Scale (19). To capture past year racialized heterosexism and/or cisgenderism, students were asked to indicate whether they experienced each item in the past year (yes/no). A composite score was calculated by summing responses across the items (range, 0-5; mean [SD], 1.21 [1.53]; α = .63).

Psychological distress
The previously validated Kessler-10 (23,24) was used to measure current psychological distress among SGM SOC.

Covariates
Linear regression models were adjusted for continuous social isolation (25), parental financial dependence, and age, and adjusted for dichotomous sex assigned at birth (1 = female, 0 = male), gender identity (1 = noncisgender identity, 0 = cisgender identity), sexual orientation (1 = any nonbisexual sexual orientation, 0 = bisexual orientation), educational program (1 = undergraduate, 0 = graduate), Latinx ethnicity (1 = Latinx, 0 = not Latinx), race (1 = any nonwhite race, 0 = white race), living with parents (1 = living with parents, 0 = not living with parents), and being out to parents (1 = out to parents, 0 = not out to parents). with psychological distress (using independent samples t tests and 1-way analysis of variance [ANOVA] F tests) were conducted. Afterward, the bivariate associations between past year LGBTQrelated minority stressors, and racist microaggressions, with psychological distress were examined by using simple linear regression. Next, covariate-adjusted multiple linear regression modeling was used to examine the associations between past year LGBTQrelated minority stressors, and racist microaggressions, with psychological distress; interactions between significant LGBTQrelated stressors and racist microaggressions were examined. Alpha was set to less than .05.

Sociodemographic characteristics and psychological distress
Among SGM SOC in the sample, more than half identified as female (72%) and cisgender (gender identity that corresponds with sex assigned at birth; 71%); both sex assigned at birth (P < .001) and gender identity (P = .02) were significantly associated with psychological distress (Table 1). Although sexual orientation varied, bisexuality (30%) was the most prevalent; sexual orientation (P = .02) was significantly associated with psychological distress. Most of the sample were undergraduate (74%) students, and average age was 21.7 years; age and educational program were not significantly associated with psychological distress. A total of 38% of sample participants identified their ethnicity as Hispanic or Latinx. A plurality identified their race as white (39%), Asian (36%), Black or African American (26%), and/or another nonwhite race (19%; including Native Hawaiian or Pacific Islander, American Indian or Alaska Native, and a race not listed); only white race (P = .01) was significantly associated with psychological distress. Most of the sample indicated that they were financially dependent on their parents at some level (85%); parental financial dependence was not significantly associated with psychological distress. Approximately 64% were out to their parents and currently living with them; being out to parents and living with parents were not significantly associated with psychological distress.

Multivariable associations with psychological distress
Covariate-adjusted multiple linear regression modeling that tested the associations of past year racist microaggressions, and LGBTQrelated stressors, with psychological distress are reported in Table  3.

Discussion
Our study aimed to explore the effect of past year racist microaggressions, and LGBTQ-related minority stressors, and their association with psychological distress among SGM SOC. Our study hypothesis was partially supported: racist microaggressions and LGBTQ-related family rejection and internalized LGBTQ-phobia were associated with greater psychological distress. Though LGBTQ-related identity concealment, victimization, and racialized heterosexism and/or cisgenderism were significant in initial bivariate models, they were no longer significant in the final multivariable model. Study findings indicate that racist microaggressions, along with LGBTQ-related family rejection and internalized LGBTQ-phobia, may have a unique effect on the mental well-being of SGM SOC; the findings highlight the importance of using minority stress theory, CRT, and intersectionality framing in tandem toward eliminating the mental health inequities faced by SGM SOC.
In multivariable analyses, racist microaggressions, LGBTQrelated family rejection, and internalized LGBTQ-phobia were associated with greater psychological distress. These findings con-PREVENTING CHRONIC DISEASE www.cdc.gov/pcd/issues/2023/22_0371.htm • Centers for Disease Control and Prevention tribute to previous research, which has documented significant associations of racism and other LGBTQ-related stressors (ie, heterosexism, gay rejection sensitivity, and homonegativism) on mental health among SGM POC (1,2,7,8). These results add to existing research by further documenting that racist microaggressions and multiple forms of LGBTQ-related minority stressors are impactful predictors for psychological distress among SGM SOC. More research and interventions are needed to understand and address the intersectional identity-related mental health needs of these populations. Study findings are concerning given that SGM SOC are still emerging in their adulthood. Developmentally, they are in a vulnerable stage of the life course during which they are working toward establishing themselves as independent adults. Though all college students face this particular vulnerability and threat to their mental health, SGM SOC uniquely face identityrelated (ie, LGBTQ+, race, and ethnicity) mental health inequities (ie, racist microaggressions, internalized LGBTQ-phobia, and family rejection), as revealed by our study findings. These unique identity-related stressors can hinder the developmental process in addition to affecting mental health. Therefore, these stressors may have long-term implications for students' health and well-being across the lifespan.
The fact that racist microaggressions remained a significant predictor in the final model, while some LGBTQ-related minority stressors did not, is noteworthy. Much of the existing minority stress research literature is not inclusive of racial identity-related stressors and their impact on mental health; our study findings suggest that racist microaggressions are at least as impactful toward the mental health of SGM SOC compared with LGBTQrelated minority stressors. Lastly, study findings on racist microaggressions are meaningful, in that they highlight 1) the power imbalance that exists between white SGM people and SGM POC (students in this case), 2) the manifestation of this power imbalance as racist microaggressions perpetrated by white SGM people, and 3) the consequential mental health inequity faced by SGM SOC (ie, greater psychological distress). These intracommunity racist microaggressions likely have implications for LGBTQ+ community belonging among SGM SOC and POC and warrant further investigation into intracommunity stress faced by SGM SOC and POC and the effect of this stress on their mental health and wellbeing. There is a great need to move beyond traditional models of minority stress toward combination frameworks that can reduce the unique identity-related inequities faced by SGM SOC and POC (eg, CRT, intersectionality, life-course perspective, minority stress theory).
Public health, mental health, and higher education responses and practices rooted in intersectional and antiracist frameworks are necessary and must address stressors above and beyond those singu-larly related to one's sexual orientation, gender identity, and race and ethnicity. There is a great need for culturally sensitive (toward racial and LGBTQ+ minority young people and students) and antiracist practice and response efforts to address racism and non-race-related SGM stressors (eg, LGBTQ-related family rejection) among SGM SOC. Study results overall suggest that racist microaggressions and some LGBTQ-related stressors (ie, family rejection and internalized LGBTQ-phobia) have a unique impact on the mental health of SGM SOC.

Limitations
Although our study has many strengths, there are limitations to consider. For instance, this study used a nonprobability and crosssectional sampling strategy, which limits our ability to generalize findings to broader populations and to make causal assessments. Further, a small overall sample size, as well as small cell sizes, likely affected statistical power and ability to detect significant interactions between LGBTQ-related minority stressors and racist microaggressions. The study also implemented a retrospective self-report data collection strategy, which increases risk for recall and social desirability biases. Additionally, our study measure of racist microaggressions only captured these microaggressions perpetrated by white LGBTQ people, which likely underestimates the overall experience of racist microaggressions perpetrated by white people in general. However, significant findings were still detected, suggesting the salient impact of measured and unmeasured forms of racist microaggressions. Further, linear models and quantitative data have the potential to misrepresent the realities of SGM POC because of limitations in being able to capture the complexity of sociohistorical-demographic diversity within and between groups. Future researchers should intentionally center the needs of SGM SOC to allow for analyses examining within-group differences across diverse categories of sex, gender identity, sexual orientation, age, race, ethnicity, and nationality, and those marginalized by precarious socioeconomic positions. Lastly, the study was conducted during the first months of the COVID-19 pandemic, which may have had an influence on study findings. Yet, the study reveals how LGBTQ-related stressors and racist microaggressions affect mental health among SGM SOC amid the COVID-19 pandemic, and highlights the importance of intervention, practice, and policy to address the intersectionality of mental health challenges among SGM SOC and POC. LGBTQ-related stressors, highlighting that SGM SOC are uniquely affected by racist microaggressions above and beyond LGBTQ-related stressors alone. Study results also indicated that SGM SOC are uniquely affected by LGBTQ-related internalized LGBTQ-phobia and family rejection. Therefore, university and off-campus therapists, and online, text, and hotline crisis, mental health, and social support resources should intentionally prioritize extending access to culturally sensitive mental health and social support services for SGM SOC by increasing visible allyship (eg, brown and black stripes on pride rainbows), increasing financial accessibility of services, representation of SGM providers of color, and providers' awareness and competency in addressing intersectional mental health concerns. The public health, mental health, and higher education (and K-12) communities are urged to act by supporting the hiring of professionals with training and expertise in LGBTQ+, antiracism, intersectionality, and social justice concerns as well as the dissemination of existing minority stress reduction (26,27) and family acceptance (28) resources within mental health and education contexts. Professionals who can center the urgent need for antiracist and intersectional framing of these resources (29-31) that addresses racism as well as LGBTQ-related stressors experienced by SGM SOC are desperately needed. Lastly, higher education (and K-12) communities (eg, LGBTQ+ student center directors, administrative leaders, professors, teachers, counselors, principals), particularly at predominantly White institutions (PWI), given the greater risk for white-centered LGB-TQ equity efforts and racism perpetrated by white LGBTQ people, are implored to engage in antiracist and intersectional inclusive response practices and advocacy (32-34) that 1) fully embrace SGM SOC and those with other marginalized statuses and identities (eg, undocumented immigrants, foreign nationals, and non-Christian religion affiliated), 2) aim to eliminate mental health inequity driven by racism and other identity-related oppressions (eg, LGBTQrelated minority stress), and 3) promote increases in opportunities that well position SGM SOC to thrive and succeed across the life course. Useful models of relevant programs and initiatives can be found in work done at HBCUs, where efforts to provide critical intersectional and inclusive support for SGM SOC are ongoing, including developing inclusive admissions policies; providing affirmative and culturally cognizant health care, therapy, and peer education services; and establishing gender-inclusive housing programs (35,36).

Implications for future research
It is critical for future researchers to replicate and extend our findings and continue to investigate the role of racism in pathways of LGBTQ+ minority stress to mental health, which differ substantially from examining SGM stress among SGM POC, or considering general discrimination in studies of SGM stress. More research is needed to develop and psychometrically test tools that as-sess different types of racist experiences among SGM POC and are applicable to the experiences of subgroups within SGM POC (eg, by differences in sexual orientation, gender identity, race, ethnicity, nationality, and immigration status). Such research is necessary for effective mental health, public health, and higher education interventions that work toward the elimination of racism and other types of social and health injustices and inequities. As public health scholars, we have a responsibility to address health disparities and inequities that are maintained through social systems of marginalization and oppression, such as racism. Intentional health equity approaches are urgently needed in public health research to eliminate health disparities and inequities among historically marginalized groups, such as Black, Latinx, Indigenous, and other POC, as well as LGBTQ+ people. It is imperative to apply critical social paradigms, such as CRT, intersectionality, and minority stress theory, in combination to address inequality at the nexus of SGM and racial or ethnic minority identities or both. Such frameworks aim to eliminate health inequities by revealing and challenging complex structural and historical systems of power and oppression that continue to reinforce multiple forms of social exclusion to the detriment of the health and well-being of LGBTQ+ young POC. We thank the study participants for sharing their personal experiences amid the COVID-19 pandemic. We also thank LGBTQ+ Students and Allies in Public Health at the UMD, the UMD Prevention Research Center, and various other UMD-affiliated individuals and organizations that supported this work. We also thank the various student affairs and diversity offices, LGBTQ+ student centers, and professors and colleagues across the US who do deeply valuable work for marginalized people in their communities and made this study possible. Lastly, we thank Dr Mia-Smith Bynum for her early contributions to this manuscript.   PREVENTING CHRONIC DISEASE VOLUME 20, E63 PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY JULY 2023 The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions.